Ramblings of an Emergency Physician in Texas

Expectations, or Letting People Down

One of the big joys of Emergency Medicine is helping patients. It’s truly enjoyable to suture a laceration, to reduce the dislocation, to give solace to the suffering (usually pain medicine, but not always, sometimes it’s a hand to hold). These are almost always patients who present with a sudden-onset problem, be it trauma or bowel-obstruction, and that’s why I’m there (and why my colleagues are there, as well). Patient faces begin with apprehension, and are often back to normal when they leave (and some leave with a satisfied look I take as the reflection of a job well done).

Then there are those patients I cannot help but let down. They come to me with vague complaints that have gone on for years, a pain they cannot describe or can describe too well, a discomfort that nags, a rash that won’t wane, a twitch that won’t stop or a balance that won’t start. They have seen specialists too numerous to mention, have tried medicines/potions and remedies that run the gamut of medical experience, they’ve done their exercises and, still, they want for a remedy.

I have finally learned that there are some patients I probably won’t be able to help medically and that it’s actually cruel to let them think otherwise. For instance, the patient with the low back pain that’s been to seven neurosurgeons (had three operations), been to the Mayo Clinic and to innumerable chiropractors, who looks at me and says “I need to get better”, what’s causing the back pain? Realistically, what can I offer that a myriad of specialists couldn’t? Oh, I’ll do the entire LBP exam, do a history looking for zebras and other horrible causes of back pain, and occasionally I’ll want to do some tests to rule out an emergency.

I used to leave the room with the generic “We’ll get you some pain medication and do some tests”, and then return to the room after some time, when the tests are back, and go through a prolonged ‘isn’t there anything you can do’ session with the patient and their family. They know there’s not, really, but I left that door open, and it’s at least partly my fault.

So now I let them down early. Yes it’s disappointing but I think it’s healthier for them (and me), in the long run. “You’ve had this for x years, you’ve seen about a dozen specialists; as a general rule, if a bunch of specialists cannot figure it out in their offices with all the studies, tests, etc. we’re unlikely to in the ER” is now my general start-of-the-letdown, and even the least reasonable from an expectations standpoint seem to get it: I’ll try, but it’s unlikely. Now the patient doesn’t spend the next hour-plus building up hopes to be dashed-yet-again. As memory serves I’ve never made the terrific diagnosis for the unfixable complaint, and it’s not for lack of trying. Some things I cannot change.

It’s disappointing for me, too. I’d much rather say ‘here’s the diagnosis, and the cure’, but it doesn’t work that way in real life. Maybe some of the letdown is for me. Okay, no maybe about it.

We’re pretty good in the ED with acute problems, less so with the chronic ones, and dismal with the ones nobody can solve. Sometimes expectation management is the best we can do, for everyone.

(General disclaimer: I do a real history, a real physical exam, and listen to my patients. I don’t prejudge anyone, and the above applies only at the very very end of the patient interaction, and not before.)

Comments

This is where working in the ED isn’t so different that out in practice, and it’s where honesty can lead to less wasted time and less waste of healthcare dollars.
I’ve seen so many people who have seen almost every other neurologist in town, several out of town, had repetitive scans and other tests. It’s one of the reasons why we (since we have the “luxury”) require that we get reports and scans before we will schedule the patient, since after seeing so many people it’s very unlikely that anything needs to be repeated once again.
And in the acute care setting, there are many problems that just are not acute and don’t need some megabuck workup — you deal with any acute issues as needed, then followup outpatient.
It’s important to get this message to the patient as straight as you can — this is not an acute problem that demands an answer now. If there was anything serious going on it would have been obvious by now. One can have the confidence to say these things, as you say, when you have actually talked to the patient and examined the patient — if it looks like a duck, smells like a duck, and quacks like a duck, it’s probably a duck.
And I don’t have any problem telling a patient straightaway, “I don’t think I can help you.”

After they’ve described at length their metallic taste in the mouth, their fleeting one second pains, their nonphysiologic distribution of numbness, their bloating and fatigue and so forth, it’s sad to see their crestfallen expression when we disappoint them. But I too find it’s better to get that out of the way early.

I often add the following:

“I’m not telling you that these symptoms are all in your head (psychosomatic), but I will tell you that after all the negative tests you have undergone it is becoming increasingly more likely. And patients with these symptoms often benefit from medications for anxiety or depression, because those medications have effects on the nerve conduction system as well as the psyche. So until you find the specialist who can give you a more specific diagnosis, how about trying some ________.”

Would you rather not find something or find something that has progressed?
Lately, we’ve had a rash of disease that has evaded the specialists. For instance, a few weeks ago a lady presented to the ER with increasing right leg weakness and numbness, dysuria which was new, and a history of cancer. Her doctors had done all sorts of imaging on her L-spine with no findings regarding the right leg weakness. The ER done MRI of the t-spine discovered the new tumor.
It doesn’t bring the same emotions as finding the remote under the couch cushions after everyone has looked.

Bravo for a well-written post. I appreciated the fact that you included that you still do a complete H&P and treat them as you would any other patient….because I couldn’t. It was the realization that I could not stifle my impatience and annoyance at people who present to the ER with a ridiculous C/C that shifted my career plans away from emergency medicine. I truly do admire a good ER doc who can wade through the bullshit patients and still be sharp enough to catch a truly sick one when they present.

Mike, would you prefer, “I don’t have a diagnosis, but her symptoms are concerning enough to warrant some observation.”? Just so you know, emergency medicine is a specialty quite unlike IM, with its own approaches to diagnosis and treatment. Sometimes we have more pressing concerns than getting an obvious admit fully packaged for you.

House whisperer, I’m not talking about the ones with the white count of 20K or the fever of 103. I mean the ones where its a social admit or a case where they could have observed for another hour or just taken a diagnostic stand and sent them home. I always give the ER the benefit of the doubt on the ones who look well now, cause I wasnt there when they came in. But when I’ve worked with ER prelims who are rotating through medicine, they groan as much as I do, so its not just me.

It’s also the same here in the country I’m practicing. Actually, there are even some who continually go to the emergency room for chronic problems. Somehow, some of my fellowmen still cannot distinguish between an emergency room and an outpatient clinic. Most would tell me that they get tired having to lineup for outpatient consult that’s why they go to the emergency room. It’s kind of frustrating for me that I’ve to explain to them that they shouldn’t be doing it that way, for their own sake. Follow-up consultations are not done in the ER. But, well, still people are stubborn.

About those who are chronically ill but the doctors can’t seem to find out what’s wrong with them, it’s hard having to explain to these patients that there’s nothing that I can do for them in the ER. But in situations like that, I try to tell them that all the tests have been done for them as ordered by the specialists they have seen, but the problem is, although modern medicine has improved very significantly in the last few decades, still it has limitations.

From the patient POV, sometimes at least telling us what it isn’t (like 911 doc said) can be helpful. I ended up in the ER a couple of months ago (I’ll spare you the details — see my April archive if you’re super-curious) and at least the ER doc was able to tell me that I wasn’t about to croak from prolonged blood loss, which was my concern at the time.

My tests were so perfect it was disgusting. When I saw my regular docs the tests continued to be impressively normal, which makes putting up with my personal health situation a bit of a PITA, but at least the ER was able to tell me, when I was scared nerveless, that not only was I not going to die but that I was revoltingly healthy.

Eh, it can be a double-edged sword. Plus side? I get to nag my family for a long, LONG time ;)

Maybe I’m weird, but I thought ER physicians were for emergencies. I do not want an ER physician diagnosing anything more than the presenting emergency – that isn’t their specialty. I want them to be well-versed in all the varieties of emergency medicine and how it presents.

I do know that in my neck of the woods there is a dearth of walk-in clinics for those who are without regular doctors and become sick. Now in certain circumstances, taking a complete history makes sense. But, it seems to me this is a contributing to the costs of the ER.

I couldnt agree more with your sentiment as you wrote ‘maybe some of the letdown is for me’. I believe the practice of medicine is largely about people-pleasing. In the end, however, patients appreciate humility over arrogance. Furthermore, admitting to a patient that you dont have all the answers garners far more respect than disingenuity.

Sometimes I start the consultation by summarising their entire previous medical history in front of the patient. This shows that I am aware of their case, and really builds a trust and rapport. Patients appreciate the impression that you have already taken the time, care and effort to find out everything about them.

Then I cut to the chase by directly asking what exactly they want from me today.

Often with these patients, what they want is not purely “medical” (i.e. a diagnosis or cure). There is a hidden agenda – fear, isolation, stress, strained coping mechanisms, breakthrough pain, grief, being at the end of one’s tether, etc. Sometimes the patients themselves haven’t thought about exactly what led them to present to the ED that day! This sort of direct questionning certainly helps to crystalise in their minds what their expectations for the consultation are.

By identifying this hidden agenda early in the consultation the Emergency Physician can focus the consultation on delivering precisely what the patient needs at that crisis point in their chronic illness, rather than offering what he assumes is needed.

I wish there were more docs like you in the world. Sometimes (as a patient with chronic pain), flareups send even the best coping mechanisms out the window, and a few days of pain meds literally will make the difference between feeling absolutely miserable/potential SI without a serious plan, but a desire to end it all, and being able to ride out the flare in more comfort until you can get to your specialist- especially if the specialist is hundreds of miles away.

I’ve had docs who cut to the chase, didn’t think I was drug seeking as an addict, and treated me like a person with a SERIOUS emergency- and yes, Migraines that go over 72 hrs without a 4 hr break in pain while awake IS a medical emergency… especially for those with other potential stroke risks… But, even the regular Migraineur in Status Migrainousus is at risk of a TIA…. and needs it broken, either via Mag Sulfate, a drug cocktail, or whatever has a hx of working for the patient previously. When a doctor asks me what has worked previously, and doesn’t dope me up on narcs when I don’t want them- just Mag Sulfate and Dexamethasone and Zofran- I feel like I’ve hit the lottery.

For my neck, however, sometimes I DO need the narcs for a few days with muscle relaxants to get me through and to keep my head from getting involved in the pain cycle. And then- the 2 times I’ve HAD to go the the ER, it was even worse than being a Migraine Patient- which I thought was the “low of the low” on the totem pole of ER physicians’ emnity… I was wrong, apparently. Chronic pain patients in crisis really need more doctors like you, who treat them like human beings, and ask what brought the patient there today. Sometimes, it’s ’cause you can’t take it anymore and can’t get to your specialist immediately, or your PCP won’t prescribe Narcs ’cause of FDA scares, and it’s literally the last hope you have. And other times, it’s for the flares that last longer than you have rescue meds for, and can’t get them called in over a weekend… We, the patients, are totally in your hands. It hurts even more than the physical pain when I’m mistreated by someone who swore to “due no harm” and makes the patient even more desperate, and SI may increase.

Thank you for caring, and treating us like any other patient that you may see during your day. You are a gem, and I just wanted to let you know how much people like me appreciate people like you.